Life-threatening hypereosinophilic syndrome in a patient with rheumatoid arthritis: a case report

Hypereosinophilia is unusual in rheumatoid arthritis (RA), but can occur in severe long-lasting disease, especially in patients with extra-articular manifestations and high titers of rheumatoid factor (RF). The association of RA and hypereosinophilic syndrome (HES) remains yet poorly known. We present a case of a 46 years old woman with long-standing untreated RA, that presented to emergency department with severe symptoms of constrictive pericarditis with cardiac tamponade and bilateral pleural effusion, that progressed to cardiac arrest, associated to symmetrical polyarthritis and pruritic erythematous skin papules. She was submitted to urgent pericardial drainage and partial pericardiotomy. Laboratory analyses revealed hypereosinophilia, and elevated inflammatory parameters and immunoglobulin E. The histological study of the pericardium showed results consistent with inflammatory fibrinous pericarditis. Taking into account the presence of some characteristics that are usually present in cases of reactive HES instead of idiopathic HES, and after an intensive diagnostic study, that could rule out other potential causes of secondary HES, the diagnosis of HES associated with RA was made. She started glucocorticoids during hospitalization and methotrexate 15mg per week at the first outpatient rheumatology visit. After 12 weeks of treatment, we considered that she was in clinical and analytical remission, consistently maintaining that after a complete tapering of glucocorticoids. This case illustrates that clinicians should be aware that HES (including severe life-threatening cases) can occur in patients with RA, especially in cases of long-lasting disease with high titters of RF and without treatment, even in the absence of extra-articular features.

The effects of physical exercise on axial spondyloarthritis - a systematic review

AIM

To collect and summarize the available scientific evidence that evaluates the effects of physical exercise interventions on axial spondyloarthritis (axSpA).

METHODS

A systematic review was conducted in accordance to the guidance of Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) to collect randomized controlled trials on the PubMed, Embase and Web of Science Core Collection databases. The search strategy included terms regarding physical exercise interventions targeted to axSpA participants and all of its variants in multiple combinations adapted to each one of the databases regarding its own special requirements. Several outcomes were defined: Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath ankylosing spondylitis functional index (BASFI), Bath Ankylosing Spondylitis Metrology Index (BASMI), ASDAS (Ankylosing Spondylitis Disease Activity Score), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), the 36-item short form health survey (SF-36) and the Ankylosing Spondylitis Quality of Life questionnaire (ASQoL). Two independent researchers screened the titles and abstracts followed by full-text analysis when suitable, using EndnoteTM online. Selected articles, according to exclusion/inclusion criteria defined, were submitted to data extraction and bias assessment was performed for each study's outcomes using the Cochrane risk-of-bias tool for randomized trials.

RESULTS

A total of 2063 articles were identified through the electronic databases search. After removal of duplicates, 1435 were eligible for screening, of which 45 articles went through full text evaluation. Only 24 articles met the inclusion/exclusion criteria. Physical exercise contributes for a statistically significant improvement of BASDAI in 13 studies, BASFI in 10, BASMI in 6, ASDAS in 3, CRP in 2, ESR in 1, SF-36 in 2 and ASQoL in 3.No major adverse effects were reported and an overall benefit was noted with the implementation of physical exercise as a treatment modality for axSpA.

CONCLUSION

Physical exercise seems to be an effective non-pharmacological therapy for axSpA, with positive effects in disease activity, physical function, and quality of life.

Predictors of overall mortality among people living with HIV/AIDS in Brazil, 2007-2015

Background

In Brazil there are 926,742 people living with HIV/AIDS (PLWHA). Despite the introduction of antiretroviral therapy (ART) in 1996 and treatment for all in 2014, mortality has increased in some regions. This study aimed to estimate the factors associated with overall mortality in PLWHA to recommend public health actions.

Methods

We studied PLWHA aged ≥18 years old, followed-up from 2007 to 2015 in the universal health system in Brazil. We used a national database (disease reporting, laboratory tests, ART and death notifications). Kaplan-Meier method and Cox model were used in survival analysis. The outcome was all-cause deaths. The explanatory variables measured at baseline were sociodemographic characteristics, HIV transmission mode and coinfections by hepatitis B (HBV) and C (HCV). The time-varying variables were CD4 cell count, viral load (VL) and ART status.

Results

Study population (n = 411,281) was mainly male (61%), under 40 years old (61%), Caucasian (37%), with basic education (43%), heterosexual HIV-infection mode (41%), resident in Southeast region (48%). The co-infection rate was 2.5% for HCV, and 1.4% for HBV. Median time to ART initiation was 83 days. During the follow-up period (median: 4 years), 61,757 deaths occurred (6% HCV-coinfected and 2% HBV-coinfected). The global mortality rate was 3.44 [95% confidence interval: 3.42-3.47] per 100 person-years (PY) during 1,793,417 PY. The factors associated with increased mortality in multivariable analyses were male gender, age over 40, non-Caucasian race, HIV infection by drug use, resident in North, Northeast and South regions, HCV and HBV coinfection, VL ≥ 200 copies/mL and starting ART with CD4<200 cells/mm3.

Conclusions

Although PLWHA start ART in less than 3 months after the beginning of follow-up, there is still late treatment (at CD4<200 cells/mm3). Screening should target all populations regardless of risk group. Coinfected individuals should also be early treated for HCV and HBV infections.

Key messages

The results of our study show that all populations should be target for HIV screening regardless of risk group. PLWHA coinfected with hepatitis B and hepatitis C should be also early treated for hepatitis coinfections.

Hemorrhagic stroke: experience of an internal medicine department

Stroke is the third leading cause of death in most industrialised countries, among adults aged 65 years or more. In Portugal, however, it is the leading cause of death. Intracerebral hemorrhages comprise approximately 10 to 15% of all strokes. This particular type of stroke is associated with a worse prognosis. There is little published data concerning stroke in the Portuguese population, especially on the hemorrhagic type of the disease. The aim of the present study was to improve our knowledge on the epidemiology of hemorrhagic strokes in our community. The hospital charts of 60 patients with intracerebral hemorrhage who were admitted to our wards during the years of 1997 and 1998 were retrospectively reviewed. There was a predominance of male patients aged over 65. In most cases (78.3%), no causal factor was identified (spontaneous or "primary" hemorrhagic stroke). Hypertension was present in 80% of cases and was the most common risk factor. The percentage of putaminal and thalamic hemorrhages (48.3%) was similar to the percentage of lobar hemorrhages (46.7%). This differs from other studies. The prognosis of our patients was fairly good, with 38% of all cases being independent at thirty days. The 30-day case fatality rate was 10%. As in other studies, advancing age, a low Glasgow Coma Scale score, a large hemorrhage size and the intraventricular extension of blood were associated with a worse outcome.

[Psychiatric emergency service in a university general hospital: a prospective study]

OBJECTIVES

The aim was to carry out a prospective study about the characteristics of the public seen at a psychiatric emergency room and of its service.

METHODS

The data were acquired though a protocol developed for this study and applied to all the patients seen during two months.

RESULTS

600 protocols were filled out, corresponding to 96.5% (487 patients) of the attendance during the study period. Most of the patients seen were males, single, with a low educational level, professionally inactive and living with their families. The most frequent diagnoses were psychoactive substance use disorders (26.3%), schizophrenia (15.5%), manic episode (11.8%), major depression (10.9%) and non-psychotic disorders (10.9%). There were differences between gender in some diagnostic categories. After initial evaluation, 2/3 were medicated, (1/2) stayed under observation, and (1/4) stayed more than 10 hours in the service unit. About 20% of the attendance resulted in hospitalization and 60% in referrals to outpatient services. Discharges due to evasion represented only 2.0% of the total. Returning service users did not differ from those seen only once to what concern marital status, professional situation and household conditions. However, returning users presented a higher frequency of previous hospitalization and psychotic disorders.

CONCLUSIONS

Individuals with severe psychiatric disorders were seen in an actual emergency situation. The psychiatric emergency service has been expanding its actions and has been an effective part of the mental health service network.

Problems of patients with chronic aphasia: different perspectives of husbands and wives?

During the early phase following stroke, patients with aphasia and their families are totally involved in the rehabilitation programme, but later, in the chronic phase, after discharge, the family generally has no support and many problems may arise or become more acute and provoke disturbances in this system. The patients with aphasia and their spouses may feel the situation differently according to their own characteristics, including gender. The present study includes 55 spouses of patients with chronic aphasia and 37 controls (spouses of subjects without physical or cognitive impairments) who filled out a questionnaire concerning their respective spouses (European Brain Injury Questionnaire--EBIQ) and some aspects about themselves. It was concluded, from the opinions expressed by the spouses of patients with chronic aphasia that they have problems in several domains not only related to communication or physical impairments. The opinions of husbands and wives of patients with aphasia, but not of the controls, were different, with more references to behaviour changes in women with aphasia. Spouses' responses also show important changes in their own lives. These results stress the importance of adequate attention to the long-term psychosocial problems of patients and relatives.

Spontaneous complaints of long-term traumatic brain injured subjects and their close relatives

Long-term consequences of head injury for patients and families are not well known, given the complexity of variables that have to be studied. Subject's self-experience is one of these less studied aspects. The purpose of this study is to examine the spontaneous complaints of long-term brain injured adult subjects to be compared to the impression of their relatives. A total of 48 chronic head trauma subjects were studied more than 6 years after injury together with a relative, usually a mother or wife. At the beginning of the interview the participants were asked to freely refer their present complaints. In general, relatives referred more complaints about the injured subjects than the injured subjects referred about themselves. This occurred in several domains: somatic, physical, cognitive, and behavioural. Memory problems were highly reported by both groups. Somatic complaints were more frequently reported by patients and behavioural problems were more often reported by relatives. Mothers and wives had different profiles or responses. Mothers' opinions were identical to those of their TBI sons in all domains. These different results must be taken into consideration so that the real needs of patients and relatives can be addressed.

Longitudinal measurement of anticardiolipin antibodies during normal pregnancy: a prospective study

We have previously shown that elevation of anticardiolipin antibodies (aCL) at the first prenatal visit is associated with increased fetal loss in normal pregnancy. The variation in aCL levels during normal pregnancy has not been established. To examine this question we measured IgG, IgM and IgA aCL levels five times during pregnancy at weeks 5-15, 16-25, 26-35, 36-37 and at delivery. Data were analyzed to determine: (a) the within and between subject variability of aCL during pregnancy; (2) the temporal trend of aCL; and (3) the relation of serial measures of aCL with maternal complications of pregnancy. We divided our cohort of 354 subjects into two groups. Group A included those subjects with consistently normal levels of aCL and group B those subjects with at least one elevated level of aCL. In group A the within subject variability was relatively low (28-34%). In group B we found wide fluctuations in aCL levels and a within subject variability of 88-91%. Subjects in group B had no increase in maternal complications of pregnancy. The present data suggest that aCL may fluctuate significantly during normal pregnancy and there is little clinical value in measuring aCL on a serial basis during pregnancy.

Rates of spontaneous mutation in bacteriophage T4 are independent of host fidelity determinants

Bacteriophage T4 encodes most of the genes whose products are required for its DNA metabolism, and host (Escherichia coli) genes can only infrequently complement mutationally inactivated T4 genes. We screened the following host mutator mutations for effects on spontaneous mutation rates in T4: mutT (destruction of aberrant dGTPs), polA, polB and polC (DNA polymerases), dnaQ (exonucleolytic proofreading), mutH, mutS, mutL and uvrD (methyl-directed DNA mismatch repair), mutM and mutY (excision repair of oxygen-damaged DNA), mutA (function unknown), and topB and osmZ (affecting DNA topology). None increased T4 spontaneous mutation rates within a resolving power of about twofold (nor did optA, which is not a mutator but overexpresses a host dGTPase). Previous screens in T4 have revealed strong mutator mutations only in the gene encoding the viral DNA polymerase and proofreading 3'-exonuclease, plus weak mutators in several polymerase accessory proteins or determinants of dNTP pool sizes. T4 maintains a spontaneous mutation rate per base pair about 30-fold greater than that of its host. Thus, the joint high fidelity of insertion by T4 DNA polymerase and proofreading by its associated 3'-exonuclease appear to determine the T4 spontaneous mutation rate, whereas the host requires numerous additional systems to achieve high replication fidelity.

[Early and delayed cardiac mortality after acute myocardial infarction in the pre-thrombolytic era. Prognosis value of an ergometric test and coronary arteriography]

PURPOSE

To determine the relationship among clinical data, attenuated treadmill stress test (ST), cinecoronaryarteriography (CINE), ejection fraction (EF) with early-late mortality in patients after acute myocardial infarction (AMI).

METHODS

Prospective study in 96 consecutive patients aged < 70 with AMI that were submitted to ST and CINE. Assessment of cardiac mortality was made 1-3 years post-AMI (period I) and at the end of follow-up (7-10 years-period II).

RESULTS

First year and 10th year mortalities were 8% and 36%, respectively. Positive predictive value for cardiac death in period I was 10% for ST, 7% for multivessel coronary artery disease (MVCAD) and 9% for left ventricular ejection fraction (LVEF) < 30, while in period II they were 45%, 42% and 50%, respectively. Actuarial survival analysis (Kaplan-Meyer) disclosed mortality rates of 53% and 20% (p = 0.06) on period II for positive and negative ST, respectively, 45% and 22% (p < 0.03) for MVCAD and single-vessel disease, respectively, and 73% and 35% (p < 0.001) for those with and without left main coronary artery obstruction, respectively. In the multivariate regression analysis (Cox's model), only MVCAD (p < 0.002), LVEF < 30 (p < 0.003), positive ST (p < 0.007) and post-AMI angina (p < 0.01) were independently related to late mortality.

CONCLUSION

Both attenuated ST and CINE are poor predictors of post-AMI early and late mortalities. However, multivariate regression analysis disclosed positive ST, MVCAD and LVEF < 30 as independent variables related to late mortality. This data indicate that myocardial ischemia, number of obstructed coronary arteries and poor left ventricular systolic function are the true determinants of post-infarction cardiac mortality.

Clinical significance of immunoglobulin A versus immunoglobulins G and M anti-cardiolipin antibodies in patients with systemic lupus erythematosus. Correlation with thrombosis, thrombocytopenia, and recurrent abortion

Serum levels of immunoglobulins (Ig) A, G, and M anti-cardiolipin (aCL) antibodies were determined by enzyme-linked immunosorbent assay in a group of selected systemic lupus erythematosus female patients. Patients were divided into three groups based on their clinical history of thrombosis with or without thrombocytopenia (group I), thrombocytopenia alone (group II), and neither of these (group III). After the aCL antibody levels were determined, the patients' obstetric histories of pregnancies and abortions were reviewed. A high incidence of one or more abortions was seen only in group I patients. A high prevalence of elevated levels of IgA and IgG (but not IgM) aCL antibodies was observed in group I patients. However, among the patients in group II, only the levels of IgA aCL antibodies were increased. In both groups, the addition of the IgA aCL determination--to the classical IgG and IgM aCL assays--increased the prevalence of positive reactors in 31.6%. These results indicate that high levels of IgA aCL antibodies correlated better with thrombocytopenia than either IgG or IgM. Also, the importance of including the determination of IgA aCL antibodies to assess properly the risk of thrombosis, thrombocytopenia, and recurrent abortions in systemic lupus erythematosus patients is demonstrated.

[Is coronary cineangiography more accurate than early bicycle ergometry test in the identification of high-risk acute myocardial infarction survivors?]

PURPOSE

To determine if attenuated early treadmill stress testing is more or less accurate than cinecoronary arteriography in the identification of high-risk acute myocardial infarction (AMI) survivors.

PATIENTS AND METHODS

In a prospective study 96 non-selected and consecutive AMI survivors underwent cinecoronary arteriography in the 4th week of hospitalization and were followed up for a period of 3 to 39 (21.7 +/- 11.0) months. One-half of the patients were randomly submitted to an attenuated heart rate-limited treadmill stress testing in the 3rd week. Seven patients were lost in the follow-up. Of the remaining 89 patients 5 died of cardiac causes. Cardiac events (death, reinfarction, angina and heart failure) occurred in 26 patients. Multivessel coronary artery disease was found in 67 patients (75%) and mean left ventricular ejection fraction was 49.1 +/- 15.6%. Positive treadmill stress testing for myocardial ischemia occurred in 20 of 43 patients (46%).

RESULTS

All patients who died of cardiac causes or who had a cardiac event had multivessel coronary artery disease, the mean left ventricular ejection fraction was 38.6 +/- 16.6% and 45.2 +/- 16.4%, respectively, and two-thirds of patients had positive stress testing. For cardiac death, multivessel coronary artery disease had better sensitivity than positive stress testing and left ventricular ejection fraction less than 0.3 (100% vs 67% vs 20%, respectively) while ejection fraction had better specificity than stress testing and multivessel coronary artery disease (87% vs 55% vs 21%, respectively). Stress testing had a better positive predictive value than multivessel coronary artery disease and ejection fraction (53% vs 38% vs 36%, respectively while multivessel coronary artery disease had better negative predictive value than stress testing and ejection fraction (100% vs 77% vs and 70%, respectively). The association of data obtained from cinecoronarography study between themselves and with positive treadmill stress testing did not significantly improve the sensitivities, specificities and predictive values in relation to the results obtained by isolated data.

CONCLUSION

In survivors of acute myocardial infarction cinecoronary arteriography is not more accurate than, treadmill stress testing and both have limited value in the identification of patients who are candidates for cardiac death or events in the first few years after AMI. A negative stress testing and coronary arteriography (one-vessel disease) is more informative than a positive one.

Associative visual agnosia: a case study

This report describes a case of associative visual agnosia caused by a left sided, cortico-subcortical, inferior temporo-occipital infarction. Performance on visual perceptual tests was normal, while it was defective on visual classification tasks. Visual agnosia was interpreted as a visuo-verbal disconnection plus a categorization deficit for visual meaningful common stimuli. The left occipito-temporal lesion disrupted the visual classification process and prevented access of visual information to language areas and limbic system. The absence of right hemispheric lesion accounted for the normal recognition of familiar faces and other unique individual stimuli such as familiar places, whose recognition occurs through contextual evocation.